Scribd
Upload
55 views8 pages

Status CP

This document provides a summary of the assessment process for patients with cerebral palsy. It outlines the various areas that are examined including: [1] patient history and development milestones; [2] physical examination of posture, range of motion, muscle strength, neurological assessment; and [3] functional assessment of activities like sitting, standing, walking. The prognosis for walking is also discussed based on the type and severity of CP as well as developmental milestones.

Uploaded by

Bayu Dp
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
55 views8 pages

Status CP

This document provides a summary of the assessment process for patients with cerebral palsy. It outlines the various areas that are examined including: [1] patient history and development milestones; [2] physical examination of posture, range of motion, muscle strength, neurological assessment; and [3] functional assessment of activities like sitting, standing, walking. The prognosis for walking is also discussed based on the type and severity of CP as well as developmental milestones.

Uploaded by

Bayu Dp
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 8

STATUS PASIEN

CEREBRAL PALSY

I. Identity
II. Anamnesis
- Chief complain & history of present illness (riwayat tumbuh kembang sebelum dan
setelah sakit)
- Riwayat antenatal, natal, postnatal (mencari factor resiko CP)
- Milestone
III. Physical examination

a. Status General
 Lingkar kepala, status gizi, posture
b. Status Muskuloskeletal
 ROM
 MMT
o Neck control : good/poor
o Trunk control : good/poor
o Upper Ext : F/WF/NF
o Lower Ext : F/WF/NF
c. DDST (gross motor, fine motor, language, personal social)
d. Functional examination :
 Sitting balance : static & dynamic
 Standing balance : static & dynamic
 Transfer :
o Lying to sitting
o Sitting to standing
 Hand function (bisa dengan MACS)
 Pola gait :
o Hemiplegic gait :
o Scissoring : cross over leg saat berjalan
o Jump gait : hip flx, knee flx, ankle planarflx saat stance phase
o Crouch gait : knee flx, ankle hyperdorsiflx saat stance phase
o Stiffed knee gait : decrease knee flx saat swing phase
o Trunk lurch : increase side-to-side trunk movement saat berjalan krn
deficiency balance
 Level GFMCS : (tabel di bawah pada usia 6-12 th)

e. Status Neurology :
 Cranial nerve :
 Tonus / spasticity :
 DTR :
 Pathological Ref :
 CNS maturation :
o Level spinal : flexor withdrawal, extensor trust, cross extension
o Level brainstem : ATNR, STNR
o Level midbrain : body righting on the body, labyrinthine righting acting on the
head, optical righting
o Level cortical : hopping, sitting, kneeling
 Assesment sensory integration : impressed (hyper/hyposensitive/sensory seeking)
o Touch
o Taste
o Hearing
o Visual
o Smell
o Proprioceptive
o Vestibular
f. Levine Criteria (bukan kriteria diagnosis CP lagi) :
 Posture
 Oral drooling
 Strabismus
 Tonus
 Evolution CNS
 Reflexes : physiological & pathological
f. Other examination :
 Cognitive
 Eye contact
 Communication ability (bisa dengan CFCS) :
o Receptive : kemampuan mendengar perintah atau sumber suara
o Expressive : kemampuan berbicara
 Deformities or contracture
o Common site contracture (AGA : pronator, wrist & fingers flx ; AGB : hip flx,
knee, ankle plantarflx)
o Scoliosis, pelvic obliquity, leg length discrepancy
o Examination for contracture hip flx :
 Thomas test
 Ely’s test
o Examination for contracture hip adduction
o Ortolani test (for hip dislocation krn dominasi hip add & int rot  tendensi
hip dislocation)
o Examination for torsional abnormality in lower extremity :
 Femoral anteversion
 Femoral retroversion
 Tibial torsion (TFA/Thigh foot angle) : normal 0-300 ext rot
 FPA/Foot progression angle : normal 0-300 ext rot
 Feeding ability
Prognosis Ambulasi (Molnar & CP Help) :
 Berdasarkan tipe CP
o Hampir 100% hemiplegia bisa ambulasi
o 85% diplegia bisa ambulasi
o 0-72% quadriplegia bisa ambulasi
 Saat usia 2 thn :
o Sdh bisa duduk  prognosis ambulasi baik
o Reflex primitive (+) & postural reaction (-)  prognosis ambulasi buruk
o GFMCS level I, II, III  prognosis ambulasi baik
o GFMCS level IV, V  prognosis ambulasi buruk
 Severe intelectual impairment  prognosis ambulasi buruk
 Saat usia 5-7 thn ada severe developmental delay & belum bisa berdiri  tidak bisa berjalan

You might also like